Brunswick_Well Abandonment_20241002

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joseph L. Zuncich 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:wA
3324-A
NC Well Contractor Certification Number 7b.Approximate volume of water;remaining in well(s): N/A (gal.)
Applied Resource Management, P.,C - j'4•.. y 3 FOR WATER SUPPLY WELLS ONLY:
Company Name k•' ' �•�'k�' •'
7c.Type of disinfectant used: FiTFi
2.Well Construction Permit#: N/A n f T c� 2W
List all applicable well coisiniction permits(i.e.UIC,County, atG,Variarce,eic.)r,ifk of� u 1/10 pound
- r' �;,-n� 7d.Amountofdisinfectantused:
3.Well use(check well use): lf,..;,;:•�t'f'C';�•dk�sy�y
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public C Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
FlIrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ;, ❑Other(explain under 7g)
❑Monitoring ❑Recovery -
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 5 pounds bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 pounds concrete
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer Remove above ground pump, break up and remove
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
well concrete pad, measure well depth and water
a.Date well(s)abandoned: 9/19/24 level, disinfect well, remove 2' of 1 1/4" PVC casing,
5a.well location: seal well with hydrated bentonite and neat cement.
James and Tammy Dowd N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2187 Forest Drive SW, Supply, NC 28462 9/19/24
Physical Address,City,and Zip SignaO&of Ce4ffied Well Contractor or Well Owner Date
Brunswick 200720708349 By signing this form, I hereby certify that the ivell(s) was(ivere) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
33 56'29.33" N 78 18' 53.18" `1, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach hell constrzietio»record(s)ifm,allable. Forin:dliple injection ornon-iiatersapply ivel/s —_ __g ---_
ONLY-witlNhesaarrrnnstrtrction'abarrdomfientu can subnne faun: 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Unknown abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 10 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Unknown (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to die following:
6d.Water level below ground surface: 3.01 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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NA 10c.For Water Suoaly&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit onejcopy of this form within 30 days of completion
of well abandonment to the codnty health department of the county where
6L Inner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
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Forth GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016